NHS 10-year plan FAQs
We recently hosted a webinar to review and discuss how the 10 Year Plan (“the Plan”) for the NHS may impact upon general practice. Our panel discussed several key topics and there was a very lively and engaged audience which helped to identify further burning questions.
What are your thoughts on an IHO being a ‘fed of feds’?
At present, the 10 year plan indicates that only NHS Foundation Trust will be able to become IHOs. Accordingly, the role of NHS Feds and “Feds of Feds” is likely to focus on Multi Neighbourhood Contracts and perhaps taking on Single Neighbourhood Contracts on behalf of PCNs.
Providers can’t contract with themselves, this would need working through.
This related to FT’s becoming IHO’s. As such, they would be providers and not commissioners but would have control of the whole health budget for a defined population, likely to be at place level (circa 500,000 patients) or above. There is an obvious risk and concern here for GP Feds and PCNs. However, it is more likely that they will sub-contract with providers at the neighbourhood level which would either be the SNP or practices operating through their PCN. This is likely to be the default position unless there are concerns about performance or quality.
EOIs as a pilot site are being accepted however on the NHS webinar they are only accepting EOIs from Places which are significantly larger than 50k patients. Do we have any understanding or confirmation yet of exactly what level this will be contracted?
This is the Neighbourhood Health Implementation Programme. This only covers solutions for a 250,000 or more population base. It therefore requires multiple PCNs to work collaboratively with their acute and community providers, social services, councils, ICB and voluntary sector partners. This is an interesting programme, but for most areas it may be too early to meet these requirements. Further information is available from ICBs including a FAQ document.
In the EOI, NHSE stated all parties have to sign, so this assumes primary care/ GP contractors all have to sign too, is this true , or could a FT express an interest and their voice be the deciding factor without primary care/GP contractors actually agreeing and signing?
This relates to the Neighbourhood Health Implementation Programme and during a recent webinar it was confirmed that the Clinical Directors would have to sign on behalf of their member practices.
Please also refer to the response above.
If IHO hold all the health budget would they have the GMS/PMS core funding transferred into their budget?
The position here is not clear. The initial indication is that core contract funding will be included within the Single Neighbourhood Contract funding (if PCNs apply for the contract) or remain with practices (if they don’t apply for the contract). However, see our response to question 5 where it is suggested that IHOs could end up holding “all primary care” funding.
Year of care for funding would imply IHO will have everything – and it explicitly mentions FT’s no other orgs as IHOs.
It is correct that only FTs can undertake the role of an IHO. There is a likely to be a high performance threshold before an FT can become an IHO, and having a surplus rather than a deficit will be a certain prerequisite. The deeper and more concerning question is whether the establishment of an IHO holding a “whole health budget” would replace the Single and Multi Neighbourhood contract funding. The 10 year plan is not clear on this but the Year of Care payments will allocate a capitated budget for a year (instead of paying a fee for a service) and “could include all primary care, community health services, mental health, specialist outpatient care, emergency department attendances and admissions.” We await publication of the draft contract pack but, if the Single and Multi Neighbourhood Contracts are annual contracts (in the same way the DES funding is refreshed annually) there is scope for these not to be renewed and for the funding to be transferred if an IHO is created.
The Single Neighbourhood Provider model would seem to ‘encourage’ the sacrifice of Core Contracts
Yes this is correct. The last government attempted to address this issue in relation to the accountable care contracts by offering to suspend the core contract rather than to terminate it. Ultimately this was not adopted as a new prime minister was appointed and PCNs became the focus. We will have a better idea once the contracts have been published. However, any entity or group of practices considering the SNP could achieve the same level of scale by merging their core contracts and forming a larger provider entity. The SNP contract could then be an optional transfer depending on what it contains. However, in a recent interview with Pulse, Wes Streeting said: “The reason why the structural reform in the 10 year plan will work, where previous attempts have failed, is because we are not interested in doing [former health secretary Andrew] Lansley-style, top down reorganisation, and coming in like a bull in a China shop to knock through things that are already working well. If you’ve got really effective GP partnerships that work and if you’ve got primary care networks that are working, why would I want to come in and say, “I think my model’s better than yours, so I’m just going to stop you doing something that’s working in order to do something else”?’ He added that Government is asking GPs to ‘step up’ in adopting the neighbourhood model, which will ‘include GP partnerships’.
There are already the murmurings of dissent and unhappiness from LMC’s etc – who clearly see this as a huge threat the traditional model (which it obviously is) – ultimately what are your thoughts of how this might progress if there was sufficient discord where GP’s refuse to engage?
If GPs (including LMCs) refuse to engage and tackle the risks here they will lose the ability to shape primary care as they want it. In the worst-case scenario, an FT or Community Trust would step in to be the Multi and possibly Single Neighbourhood Provider and would hold the budget. Although GPs would continue to hold their PMS / GMS contracts, this is likely to be at core contract income only (which may be unviable for some practices). Accordingly, there is significant risk here for practices but see Wes Streeting’s recent statements in the above response.
Significant practice income or expense reduction comes from ARRS, PCN finance streams, LES, LIS and DES. If these income streams are in the 50k contract then we are forced into the 50K deal, unless its a bolt-on?
Agreed, the shift of non-core income into the Single Neighbourhood Contract, leaving practices with core income only, is a significant challenge to practices that want to remain autonomous. These are the potential leavers the commissioners could use to try and force a change in working patterns. It would however be a very aggressive approach to take and does not align with the latest statements from Wes Streeting (see the answer to question above).
Will funding from GMS/PMS transfer to neighbourhood provider eventually?
Please see our responses above.
New GMS contract not due until 2028, is introducing the neighbourhood contract earlier a strategic way to move patients from existing GP practices to new health centres and make it difficult for GPs to sign up to the new GMS contract?
Possibly. See our responses to questions above. We will have further clarity on this once the contracts are published but it is clear that there are bot opportunities and risks for general practice, PCNs and Federations under the 10 Year Plan.
My concern is GMS will continue but if there is no new money, the ARRS, PCN funding and enhanced service will go in the 50 k contract, this would mean GMS would not be viable.
We agree and see our responses above. Practices are likely to be caught between a rock and a hard place; become a party to a Single Neighbourhood Contract and relinquish their GMS Contracts or retain their GMC Contracts and try to maintain a practice with core contract income only.
Is the neighbourhood in effect the PCN as Amanda Doyle suggested the PCN contract would roll into the neighbourhood?
Yes, the Neighbourhood will primarily be the PCN (there may be some flexibility in the population here).
There is a risk that small PCNs, especially those under 30,000, could be encouraged to join with another PCN. Many of these were formed in the early days of PCNs when the size was not strictly adhered to. In recent years commissioners have been far stricter, and have frequently rejected applications for smaller PCNs except in the most exceptional circumstances. This will be an important clarification, especially for those single practice PCNs under 30,000 patients who would otherwise be very good candidates to run their own neighbourhoods.
Neighbourhood aspirations to be mainstreamed by 2026 or 2027? Concern over how this will impact the current reset of the GMS contract at national level. Will Wes go back on his previous statements to ‘bring back the family doctor service’? Again, as an LMC we are talking to our 3 GP federations about how they see their future in the light of the plan and the proposed 2 new primary care contracts.
This is the big question. Reference – Wes Streeting quote at question 7 above. Links with other questions about GMS and practice role above.
Geographical Boundaries – if a current “neighbourhood” has several PCNs in it would they need to merge to serve a specific geographical area?
It should also be noted that the London Health and Care Partnership published an Operating Model in May which has stated that PCNs will need to realign to match the requirements of their neighbourhoods. This could be applied nationwide although it has not been expressly stated in relation to the Plan. A Neighbourhood Health Service for London – The Target Operating Model. Also, Dr Clair Fuller said recently that sites will have to be ‘geographically sensible’. Please also see response above.
If current PCN membership is outside of a logical geographical footprint (due to changes made over recent years often due to breakdown in relationships) will the SNP model reset the membership so that is fits again geographically?
We believe that is likely but we will not know until we have seen the contract. See also our response above.
There are hundreds of PCN’s below 50000 patients – so there is another section to your chart – PCN mergers to get to SNP level.
In theory this is correct but it depends on how tightly the government sticks to this number as most of the commentary indicates and intention to work at PCN level. See also our response above.
We are a larger PCN with over 100,000 patient population, how do you think this will affect us?
Larger PCNs will be in prime position to secure the Single Neighbourhood Provider contract. They have great potential to pull in the providers of other health and care services into the PCN to create a fully integrated solution for its locality. PCN Network Agreements are already set up to admit other non-Core Network Practice members.
Does anyone know how many took up the MCP offer? And are there stats on how many continued or returned?
Sorry, we don’t have this information as the MCP and PACS models didn’t really develop as planned.
What if your local FT are failing and dysfunctional, who will lead the IHO?
In that case, I don’t think there will be an IHO as an FT will have to be operating at a surplus in order to be an IHO. Accordingly, the ICB would commission the funding as it does now. The requirements for becoming an IHO are that FTs “have shown an ability to meet core standards, improve population health, form partnerships with others and remain financially sustainable over time – we will create a new opportunity to hold the whole health budget for a local population as an Integrated Health Organisation (IHO).”
That will be challenging for many FTs, but the 10 Year Plan also states that ”Over time they will become the norm”!.
Thank you for putting this on so quickly. So, are you suggesting that multi-practice PCNs would need to merge in order to become an SNP? And therefore, not merging means you can’t take the SNP and another provider would come in to take the neighbourhood services (perhaps an MNP)?
The Single Neighbourhood Provider contract is focussed at PCN level and so there should be no need for the constituent practices of the PCN to merge as they should be able to enter into the contract on a joint basis, rather than as a single entity. The position is similar for Multi Neighbourhood Contracts and their component PCNs.
10YP would you generally advise for or against becoming a partner?
Yes we believe that there is still a good role for GP partnerships, provided that GPs have considered and addressed the scale issues. If they have obtained the Single Neighbourhood Provider Contract (through the PCN) and the Multi Neighbourhood Provider Contract (through a Federation) then the GPs will collectively have control and can determine their own future, including maintaining sovereign partnerships, if they wish. Alternatively, they may wish to merge practices into an incorporated PCN model and become salaried. The risk here is that an FT becomes an IHO but, even then, the FT is likely to need a strong GP entity to lead on neighbourhood care delivery.
Where will new funding for the Neighbourhood come from? Will this be taken from secondary care?
It will be a combination of combining existing contracts including GMS income (possibly), ARRS, DES, LIS, LES work and shifting funding from the acute sector into primary care. This is seen as an essential part of the implementation of the 10 Year Plan.
Will SNPs and MNP legally be able to hold contracts as cannot directly contract with PCNs at the moment?
The SNP and MNP Contracts can be entered into by the partners of the constituent practices of the PCN personally, as neither PCNs nor practices are legal entities. There are issues to address if the contracts are held by multiple parties (such as liability sharing, allocation and use of staff, location from which services are to be provided, etc) so single contracting models (such as an LLP or a company limited by shares) will be attractive here. It is not known yet whether LLPs will be permitted to hold core contracts (GMS and PMS) although this has been much discussed and appears to be on the horizon.
Will SNPs be allowed to keep efficiency savings or will they be forced to hand back to IHO?
The rules governing IHO are completely unknown at this stage as is the SNP. However, it is noted that there will be increased financial freedom for Trusts including the ability to manage multiple year budgets and to utilise funds for their own development. It would be reasonable that a SNP and/or MNP will be given similar financial freedoms once they demonstrate the ability to operate at a suitable level of compliance and governance.
Where is the safeguards for more deprived areas? Patients don’t want to, or can’t travel even within our PCN area, so enforced “centres” of care will just increase the health inequalities.
Again, the 10 Year Plan is lacking in detail. It states that “our aim is to establish a Neighbourhood Health Centre in every community as a ‘one stop shop’ for patient care and the place from which multi-disciplinary teams operate”. That is easy to imagine in densely populated towns and cities (where travel and access can still be an issue) but not in rural areas. However, the model does not propose that there will only be one health centre. It is rather that there would be dedicated hubs at which a wider range of services would be accessible. There is no suggestion that this would replace local practices and services.
Where a Single Network Provider cannot be realised via PCN mergers (for whatever reason – be that inability to work together or rural/geographical constraints) – what are your thoughts? Will these allow smaller footprints (lower patient population) or will they bring in a larger pre existing SNP to absorb this population?
The Plan states that:
‘Where the traditional GP partnership model is working well it should continue, but we will also create an alternative for GPs.’
In this scenario if the practices are working well together within their PCN and are working well with the system, there should be no reason why they will not continue to be commissioned to provide services for their area, although this may be on a joint basis with another PCN if they do not constitute a neighbourhood on their own.
If the practices are failing to work collaboratively and cannot deliver the services required there is a risk that another provider will be commissioned to provide the services and that is a risk where practices and PCNs cannot collaborate effectively.
Could community trusts be formed to run community care – the FTs often cannot run themselves or current services.
In many parts of the country community NHS trusts do exist since the reforms to community services in 2010. In areas where they do not, they are either through the acute trust, or an alternative provider such as local CICs formed from the old PCTs or companies such as HRCG.
It is possible for new trusts to be formed including those dedicated to the delivery of primary care services and this has been a topic of conversation. This could be a longer term development rather than a short-term solution.
Who would the employ the disciplines joining the neighbourhoods? How will this effect professional pensions?
We will be producing an article addressing some of these more practical and operational questions in the context of how neighbourhood team working regardless of the provider structures later this week.
FTs become IHOs so they become your commissioner but also provider of these contracts as well. So we are all salaried by the FT is one direction of travel another threat?
The FT will not be a commissioner in the legal sense but may have control over a whole health budget, and that is the threat to GPs as practices, PCNs and Federations. In this evolution of the system, the FT is likely to require sub-contracted providers, or collaboration agreements in place, to actually deliver the services. Where general practice is fully engaged in the system there would be no reason to move to this structure unless there were significant ‘push and pull’ factors to justify the transition.
Movement of services into the community with no uniformity of form in community is very difficult – movement can be facilitated by this type of standardisation – and MNP could sub contract to core practices if you have a MNP (Fed) well aligned to their shareholders.
Yes this is likely to be a popular and powerful model as long as general practice can either control the MNP through their federated model, or have good engagement and relationships with the MNP if it is not a federation, to ensure that they remain the providers of choice for these opportunities.
Services being commissioned RIGHT NOW – with 5/10 year contracts – how are these going to be affected? They have dependencies on footprints etc that exist now?
This level of detail has yet to be published. Based on previous restructures of the NHS they are likely to be varied over the contract lifetime and then formally replaced at the end of the period to reflect the new structure.
Reality Check – if an area has no GP Federation in place – what are the odds of a hastily constructed and untested entity being deemed robust enough to hold Multi Neighbourhood Provider status?
This is a risk but it is not insurmountable. Often the MNP scale represents a collaboration of smaller federations or represents established and experienced providers in the sector. This can provide assurance for the commissioners. This has been demonstrated on a smaller scale during the formation of many of the existing federations when they secured their first contracts.
With the new service desires, comes the need for new premises. Primary Care is bursting at the seams after years of lack of capital investment. Where does this space come from!?
The Plan recognises the need to utilise existing and underutilised premises: “we will maximise value for money by repurposing poorly used, existing NHS and public sector estate”. Note here the reference to NHS and public sector estate and the inference is that practices may not be invested in if there are alternative NHS or public premises nearby. There is a recognition that additional funding is required for premises and they are exploring sources for this. Additional detail will be required.
What is the benefit of a CIC instead of GP Fed?
A Federation is a legal entity which represents the interests of its members and can hold contracts on their behalf. It can take several legal forms one of which is a CIC. A CIC is either a company limited by shares or a company limited by guarantee with 3 additional elements in its Articles of Association. Most GP Feds are companies limited by shares so it is not a case of a CIC as an alternative to a Federation but rather one of the ways the Federation is legally structured.
There are already the murmurings of dissent and unhappiness from LMC’s etc – who clearly see this as a huge threat the traditional model (which it obviously is) – ultimately what are your thoughts of how this might progress if there was sufficient discord where GP’s refuse to engage?
If GPs (including LMCs) refuse to engage and tackle the risks here they will lose the ability to shape primary care as they want it. In the worst-case scenario, an FT or Community Trust would step in to be the Multi and possibly Single Neighbourhood Provider and would hold the budget. Although GPs would continue to hold their PMS / GMS contracts, this is likely to be at core contract income only (which may be unviable for some practices). Accordingly, there is significant risk here for practices but see Wes Streeting’s recent statements in question 6.
If the starting point is that each practice selects their preferred provider, will the ICB review these applications as completely new start points and ‘build’ the SNPs, MNPs based on logical geography?
We don’t believe it will work in this way as ICBs will be looking for scale models and are unlikely to want to consider what each practice wants. Accordingly, the solution is for practices to work together (at neighbourhood and place levels) to determine a suitable organisation to express its interest in holding the Single or Multi Neighbourhood Contracts. The ICB are likely to then engage with those organisations.
Where might social care budgets land in all these neighbourhood models – both FTs and La’s have huge financial pressures and struggle to see collective budgets in any guise other than own organisational gain.
There is no indication at this stage that the budgets will be formally merged. This may be a future development once the health system restructures have been completed.
We have been running an INT for nearly 2 years with good result, what steps do you think we need to make to go to the next step?
At the neighbourhood level the first step would be to determine whether the practices are in a situation in which they would be interested in working at scale and converting to a SNP. If so, the task of planning and preparing for the organisational changes required to complete the merger over a reasonable time frame should be commenced. If the practices are not in this situation, then the focus must be on demonstrating to the organisation that secures the SNP that the practices and the PCN(s) are working with the system in a positive and stable manner and can continue to run the INT on behalf of that SNP.
If FTs wished to take over GP practice contracts it might be significant risk to the FT given the state of GP budgets v running costs. Likely if they did have a business model to support it they might replace GPs with other staff types.
It is likely that should services be delivered at this level of scale the current concepts of boundaries between general practice and community care would be restructured in their entirety. Models in which the GP becomes a ‘community consultant’ style role have previously been explored and are used in other countries. There is no suggestion that this is the express intention of the government and the key consideration is that providers would need to look beyond traditional working patterns and potentially revolutionise how services are delivered without the organisational boundaries being in place.
The problem is that practice finance is interwoven with PCN finance, you merge PCNs finance (ARRS and other funds), practices would really struggle now.
Agreed, and that is the threat to practices if they don’t want to become a Single Neighbourhood Provider, as they are going to be left with just their core contract income income. If they choose to become a SNP, they will hold the contracts and revenue for the neighbourhood so the funding would not need to be distinguished.
Lot of talk of federations, be interested to hear of your thoughts around GP/Provider collaboratives which may bring together Feds/PCNs locally and operate as a super provider for general practice/PC.
This could be the model developed at both the SNP and the MNP level. At SNP level the smaller federations covering a single or small number of neighbourhoods could potentially consolidate with the practices to create a single provider of services. Alternatively, they could hold neighbourhood specific contracts and allocate (sub-contract) the work to the practices. These may be the most common structures during the first few years. It should be noted that PCNs with incorporated vehicles could use the vehicles for this purpose. At the MNP level the scale is so large that it is difficult to see such large numbers of practices consolidating into a single provider. However, the federation would be in a perfect opportunity to secure contracts for the individual neighbourhoods and allocate (sub-contract) work across the practices. This would be a very powerful method of ensuring that general practice is represented at a scale which compares with FT alternatives. It may be a good way to secure revenue and to give stability to the member practices.
If PCNs merge into INTs, what may happen to the PCN managers if multiple PCNs merge into one INT?
All of the changes discussed in this document are focused on the form and legal structures. There is an essential element of work which is required to understand the transitional process and impact on employees, service pathways, existing contractors and most importantly the patients. This will form a key practical element of implementing these changes.
A Fed with a GP surgery in one part of the borough that signs up to a Multi neighbourhood contract presumably can then register patients from across the borough with clinics across the borough?
This will depend on how the new contracts and their related regulations govern list management and patient access. The existing regulations covering GMS contracts and PMS agreements would already permit this approach as it is driven by patient choice. The approach outlined in the scenario is fundamentally the same as a practice applying to open new branch sites and promoting their services outside of the catchment area. This is not therefore a new risk but rather one which could be addressed in a new way.
Is there an over reliance on tech in the Plan? From talking to Medical Defence Organisations they are very concerned about governance and risk to GPs.
“Analogue to Digital” and the patient having “a doctor in their pocket” (through the NHS App) is one of the three fundamental focuses within the Plan. We have not focused on it in our webinar but if there is interest in this we would consider holding a session on this topic in the future.
I wonder if FTs have any feel for how much it would cost them in management and support costs to run multiple GP practice contracts? A good number of old style PCTs who tried that soon changed their minds and re-tendered them.
Agreed and we have seen FTs back out of general practice and with FTs having to concentrate on moving from deficit to surplus, general practice should be in a good position, provided they act together at scale.
A lot of the new buildings (WiCs) built under the previous Lord Darzi Reform are closed. Many closed during the pandemic as a cost saving opportunity. I would hope the ambition isn’t to build more, but repurpose what we already have built or re-build on existing land purchased.
The Plan makes it clear that the preference is to utilise existing NHS and public sector estate as a priority. To achieve this the terms of occupation and the other issues which have led to the underutilisation will need to be addressed.
Why is there no reference to the pharmacy and dental contracts as part of the SNP/MNP – this seems to be targeting the stability of General Practice and not rattle dentist and pharmacist?
They are mentioned throughout the document as key parts of the Neighbourhood Health Team. They are not addressed in the context of the SNP or MNP model. The section on dentists does state that they will be expected to work within the NHS for longer and they provide the example of successful community dental services currently run within NHS community providers. Pharmacy is recognised as having “a vital role in the Neighbourhood Health Service” and community pharmacists are to increasingly become able to independently prescribe, with a greater role in the management of long-term illnesses and complex medication. The Plan may therefore be an opportunity to explore collaborative working models in the future.
I find myself asking more and more – would it be so bad for well performing Foundation Trusts taking the Primary Care Contracts. Other than the perceived ‘control’ the partnership model thinks it will lose – most GP’s out there want to be Doctors first and foremost…The Government might just look back with some alarm at how they drove the goodwill of the profession into Salaried mentality…
This is certainly an alternative for general practice, to move to an employed role within a NHS FT or Community Trust.
I managed a practice in Wales that was under the Health Board control and it was a real struggle. GPs would do what was required re: seeing patients and no more. At least partners will do a lot of additional work that people don’t see as it is a business.
This has always been the challenge related to salaried only models. What is the incentive to undertake the additional work which partners have traditionally undertaken. This is also a good reason why practices must be responsive to the Plan and ensure that they are able to retain control over general practice. Well structured and organised traditional practices working in a PCN across a neighbourhood will have the opportunity to secure their futures and some may decide to consolidate and operate at SNP level. They will retain the control and benefits of running the services. It is those areas where practices disengage with the requirements of the neighbourhood and fail to work collaboratively at PCN and neighbourhood level where there is an increased risk to their futures.